COMPLIANCE INFO_2003-2007 - Laserfiche WebLink

Home Browse Search

• i MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Quick Stop Market #144 Site Address: 7272 West Lane Facility Contact Person: Michael Karvelot Make/Model of Monitoring System: Gilbarco EMC B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment inspected/serviced: City: Stockton Contact Phone No.: ( 510 Bldg. No.: Zip: 95210 657-8500 Date of Testing/Servicing: 08 /18 /2005 Tank ID: Gasoline -87 Tank ID: Gasoline - 89 ■ In -Tank Gauging Probe. Model: 0847390-109 ■ In -Tank Gauging Probe. Model: 0847390-109 ■ Annular Space or Vault Sensor. Model: 734380-303 ■ Annular Space or Vault Sensor. Model: 734380-303 ■ Piping Sump / Trench Sensor(s). Model: 734380-208 ■ Piping Sump / Trench Sensor(s). Model: 734380-208 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ■ Mechanical Line Leak Detector. Model:yapodess 2000 ■ Mechanical Line Leak Detector. Model:yaporiess 2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment a and model in Section E on P e 2). ❑ Other(specify equipment a and model in Section E on Page 2). Tank ID: Gasoline - 91 Tank ID: ■ In -Tank Gauging Probe. Model: 0847390-109 ❑ In -Tank Gauging Probe. Model: ■ Annular Space or Vault Sensor. Model: 734380-303 ❑ Annular Space or Vault Sensor. Model: ■ Piping Sump / Trench Sensor(s). Model: 734380-208 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ■ Mechanical Line Leak Detector. Model: Red Jacket Fx1 ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (speciEy equipment type and model in Section E on Pae 2). Dispenser ID: 1 &2 Dispenser ID: 3&4 ■ Dispenser Containment Sensor(s). Model: 734380-208 ■ Dispenser Containment Sensor(s). Model: 734380-208 ■ Shear Valve(s). ■ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑Dis enser Containment Floats and Chain(s). Dispenser ID: 5&6 Dispenser ID: E Dispenser Containment Sensor(s). Model: 734380-208 ❑ Dispenser Containment Sensor(s). Model: ■ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dis enser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑Dis enser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of g era g such repor�Iha�also attached a copy of the report; (check all that apply): Q System set-up Q histo repo Technician Name (print): Bruce Stewart Signature: — Certification No.: 006-05-0810 License. No.: 617238 Testing Company Name: Walton Engineering, Inc. Phone No.:( 916 )373-1152 Site Address: 3900 Commerce Drive, West Sacramento, CA 95691 Date of Testing/Servicing: 08 / 18 / 2005 UN -036 - 1/4 Page 1 of 3 Rev. 06/04/01 CUPA: San Joaquin County Env. Health INSPECTOR: Dennis Catanyag ALTON `ENGINEERING, INC. www.unidocs.org